Pulmonary / Critical Care New Patient Evaluation

  Pulmonary Evaluation   Patient _________________________________________ DOB _____ / _____ / _____ MRN _____________________     ©MB and RR 2006-2008 Revised 31Oct08 e-medtoolscom  Indicates Physician Quality Reporting Initiative (PQRI) Physician Quality Measures Completion of this form meets or exceeds the documentation requirements in the 1997 Guidelines for Evaluation Management Services    Date Time   Chief complaint/Reason for consult Referring MDHistory of Present Illness  Patient is Nonverbal History obtained from  Family  Medical records  Elements of HPI: Location, quality, severity, timing, duration, context, modifying factors, associated signs and symptoms  Medications Allergies  Medications reviewed    Allergy List reviewed  Medications reconciled with Nursing Home or Hospital discharge Information   46      No food or drug allergies Past Medical, Family Social History Yes NoConstitution   Fatigue   MalaiseFever or chills   Appetite changes   Eyes   Vision changes   New painScotomas ENT/mouth   Nose bleedDental cariesDental abscessesJaw pain Respiratory   DyspneaCoughPhlegmHemoptysisWheeze Cardiovascular   Chest painDiaphoresisAnkle edemaSyncopePalpitations Gastrointestinal   Nausea or vomitingWeight changesConstipation orDiarrheaAbdominal pain Genitourinary   Urinary changesHematuriaDysuriaUrethral discharge Musculoskeletal   MyalgiasArthralgiasJoint swellingRecent trauma Skin/Breasts   MassesNew skin lesionsRashesSensitivity to sun Neurologic   HeadachesSeizuresMuscle weakness Endocrinologic   Hair lossPolydipsiaTremorsNeck pain Heme/Lymph   Bleeding gumsUnusual bruisingSwollen lymph nodes Allergy/Immunology Sinus problemsRecurrent infections Psychologic   Mood changesAgitationHallucinations  Asthma  Cerebral Artery Disease  Neuromuscular weakness  Chemotherapy  Bronchiectasis  Congestive Heart Failure  Occupational exposures  Colonoscopy  COPD  Coronary Artery Disease  Osteoporosis  ECHO/Stress Test  COP (BOOP)  Diabetes  Pancreatitis  Mammogram  Cystic Fibrosis  GERD  Peripheral Artery Disease  PFTs    Histiocytosis  Hepatic Dysfunction  Scleroderma  PapSmear  Tuberculosis  HIV/AIDS  Seizure Disorder  Prior Intubations  PAH  Hypertension  Sjogren’s  Radiation exposure  Sarcoidosis  Inflam bowel disease  Renal dysfunction/ failure  Sleep Study  Wegener’s  Malignancy  Rheumatoid Arthritis  Steroid use  Obstructive Sleep Apnea  Thrombotic Disease  CPAP  BiPAP    Thyroid disease    Malignancy   Adrenal    Colon    Melanoma  Renal cell  Thyroid  Breast  Lung  Prostate  Testicular SurgeriesSocial History / Risk factors  Denies  Yes Ever smoker  ___ # Packs X ____ # Yrs  Denies  Yes Patient has tried smoking cessation aids  Denies  Yes Chews tobacco    Nicotine replacement  Denies  Yes Quit tobacco use Quit date _________   Buproprion or nortriptyline  Patient is unwilling to quit  Nicotine receptor blockade    Patient willing to consider quitting  Patient quit, but resumed smoking    Patient willing to quit within 1 month    Denies  Yes Feels safe at home or work    Denies  Yes Alcohol use ___ Drinks per  day  week  Denies  Yes Tattoos    Denies  Yes Felt the need to cut down on drinking?  Denies  Yes   High risk sexual behavior  Denies  Yes Annoyed by others criticizing drinking?    Denies  Yes Recreational drug use    Denies  Yes Guilt associated with drinking?    Inhalational   Injectable   Ingestible   Denies  Yes Eye opener needed?    Denies  Yes Drug dependence    Narcotics  Benzodiazepines Occupational and Exposure History  Inorganic dusts ie, quarries, sandblasting, cement, stone carving, welding, plumbing, shipyard work, firefighter    Organic dusts ie, farming, building inspection, woodworking, remodeling, handling vegetable matter or animals    Noxious fumes   ie, spray painting, autobody work, working with dyes or glues, manufacturing plastic   Hot tub or Jacuzzi or High Pressure washings  Pets or feathers  Chemicals or fires   Family Medical History  Asthma  CHF  COPD  Coronary Artery Dis  Pancreatitis  Peripheral Artery Disease  Renal Dysfunction  Thrombotic disorder  Thyroid Disease  Malignancy in first degree relatives, specify   Reset Reset Reset Reset Reset Reset Reset Reset Reset Reset Reset Reset Reset Reset  Pulmonary Evaluation   Patient _________________________________________ DOB _____ / _____ / _____ MRN _____________________     ©MB and RR 2006-2008 Revised 31Oct08 e-medtoolscom  Indicates Physician Quality Reporting Initiative (PQRI) Physician Quality Measures Completion of this form meets or exceeds the documentation requirements in the 1997 Guidelines for Evaluation Management Services    Exam To qualify as a comprehensive exam:  General Multisystem requires performing ALL of ≥  9 organ systems, AND ≥  2 elements documented in each organ systemRespiratory Single Organ System Exam requires documentation of ALL highlighted organ system elements, AND ≥  1 element in every other organ system is expected Ventilator, IV Medications Labs   VentilatorMode  AC    SIMV  PC    PRVC    Other ____________  Rate  __________   Tidal Vol  __________   PEEP  __________   PS  __________   FiO2  __________   PO2/FiO2  __________   Plateau  _________  _    NonInvasive Ventilator  CPAP  BiPAP IV Medications    Pressors Dose Rate   ____________________________  ____________________________     Antihypertensives  ____________________________     Diuretics  ____________________________   Antibiotics  ____________________________  ____________________________     Sedation  ____________________________     Narcotics  ____________________________     Heparin  ____________________________   Insulin  ____________________________   Antiarrhythmics   ____________________________     Steroids  ____________________________     Paralytic   ____________________________     Thrombolytic    ____________________________     TPN Labs  \____/  /   ____ / ____ / ____ /     Constitutional ( ≥  3 vitals)   Body habitus  and Grooming  required of General Multisystem but not Organ System Exam   Height  ___________     in  cm Weight  ___________     lb  kg Temperature  __________  Pulse Rate  __________ AND Rhythm     Regular  Irregular  Blood Pressure sitting  __________ / __________    OR  standing  __________ / __________  Blood Pressure lying  __________ / __________  Respiratory Rate  __________  Optional Sats  _____  % Cardiac Output  _____  SVR  _____   Body habitus wnl  Cachectic  Obese  Grooming wnl  Unkempt ENT  Nasal mucosa, septum, and turbinates wnl  Dentition and gums wnl  Dental caries  Gingivitis  Oropharynx wnl  Oropharyngeal edema or erythema  Oral ulcers  Oral PetechiaeMallampati  I  II  III  IV Neck  Neck wnl  Erythema or scarring consistent with  Recent  Old radiation dermatitis  Thyroid wnl  Thyromegaly  Thyroid nodules palpable  Neck mass ___________________________   Jugular Veins wnl  JVD present  a, v or cannon a waves present Resp  Chest is free of defects, expands normally and symmetrically  Erythema consistent with radiation dermatitis  Scarring consistent with old, healed radiation dermatitis  Respiratory effort is wnl  Accessory respiratory muscle use  Intercostal retractions  Paradoxic diaphragmatic movements  Chest percussion wnl  Dullness to percussion  Lt  Rt  Hyperresonance  Lt  Rt  Tactile exam wnl Tactile fremitus    Increased       Decreased  _____________________________________   Clear to auscultation  Bronchial breath sounds  Egophony (E to A)    Rales  Rhonchi  Wheezes  Rub present ________________________  CV  Clear S1 S2  No murmur, rub or gallop  Gallop  Rub  Murmur present  Systolic  Diastolic Grade     I  II  III  IV  V  VI  Peripheral pulses palpable  No peripheral edema Peripheral pulses  Absent  Weak GI  Abdominal exam wnl Mass present  LUQ  RUQ  LLQ  RLQ ____________________   Pulsatile  Liver and spleen palpation wnl Unable to palpate  Liver  Spleen Enlarged  Liver  Spleen Lymph (  ≥ 2 areas must be examined)    Lymph node exam wnl Areas examined  Neck  Axilla  Groin  Other ___________________ Lymphadenopathy noted in  Neck  Axilla  Groin  Other ___________________  Musc  Muscle tone within normal limits, and no atrophy notedTone is  Increased  Decreased  Atrophy present  Gait and station wnl  Ataxia  Wide based gait  Shuffle Patient leaning  Rt  Lt  Front  Back Extrem  Exam wnl  Clubbing  Cyanosis  Petechiae  Synovitis  Rt  Lt ________________________  Skin  No rashes, ecchymoses, nodules, ulcers  Periungual telangiectasias  Splinter hemorrhages Neuro  Oriented  58(Pts with Community Acquired Bacterial Pneumonia)   NOT oriented to  Person  Time  Place  Affect is within normal limits OR  Patient appears  Agitated  Anxious  Depressed Glasgow Coma Score E _____ V _____ M _____ APACHE II Score __________   Pulmonary Evaluation   Patient _________________________________________ DOB _____ / _____ / _____ MRN _____________________     ©MB and RR 2006-2008 Revised 31Oct08 e-medtoolscom  Indicates Physician Quality Reporting Initiative (PQRI) Physician Quality Measures Completion of this form meets or exceeds the documentation requirements in the 1997 Guidelines for Evaluation Management Services    Data Reviewed   Impression  ER Notes  Old medical records  Labs  Radiology data  ECHO  ECG  Stress Test  Pulmonary Function Test  Nursing Notes/Vitals log Care Coordinated with  Patient  HCPOA / Surrogate  PCP  Consultant  Case Management or Social Worker  Pharmacy  Nursing  Physical Therapist  Occupational Therapist  Speech Therapist Recommended Actions  Aggressive pulmonary toilet  DVT prophylaxis    Stress ulcer prophylaxis  Daily sedation vacation andneurologic assessment  Head of bed elevated > 30 Degreesat all times  Intense glycemic control  Insulin infusion  Central line change or removal (send tip for culture)    Physical therapy  Enteral/Parenteral feeds  Smoking cessation aids  Pneumonia vaccine prior to discharge  Influenza vaccine prior to discharge   Recommended Diagnostics  PPD Testing  12-lead EKG  Echocardiogram  Sputum culture  Bacterial  Fungal  AFB  Blood culture  Urine culture  CSF culture  CBC with differential  PT, PTT, INR  BMP (with calcium)  HIV  Hepatitis panel Code Status     Patient is a FULL CODE     DO NOT ATTEMPT RESUSCITATION     Patient has completed advanced health care directives   47  HCPOA is _______________________________________ Signature ________________________________________  cc  __________________________________